For the past few decades, the predominant model of healthcare management used by most health care plans in the managed care industry has been one that focuses primarily on approving or denying coverage for medical procedures based upon specially developed criteria. This system has been subject to some criticism from doctors who feel that their treatment decisions should not be questioned, and from patients who feel that their health care plan places undue emphasis on financial consequences at the expense of sound medical care. Further, the current model employed by health care plans fails to place the appropriate amount of emphasis on providing proactive care for plan members.
Studies have shown that an emphasis on proactive care can improve a health care plan member's overall health and well-being. Proactive care can also reduce the overall expense to a health care plan by replacing expensive medical procedures and treatments with less expensive proactive care activities. One technique for identifying plan members having a need for proactive care services is through the use of a predictive model for health care utilization. An exemplary system for predicting health care utilization is disclosed in co-pending U.S. patent application Ser. No. 09/635,911, entitled “System and Method for Modeling of Health Care Utilization,” by Gerald L. Lutgen et al., filed Aug. 10, 2000, now issued U.S. Pat. No. 7,44,291 on Oct. 28, 2008, which is hereby incorporated by reference in its entirety. Another example of such a system uses a predictive model in combination with an identification of a factor influencing a plan member's amenability to proactive care intervention. Such a system is disclosed in co-pending U.S. patent application Ser. No. 09/733,215, entitled “Method for High-Risk Member Identification,” by Badri N. Prasad et al., filed Dec. 8, 2000, now issued as U.S. Pat. No. 7,640,175 on Dec. 29, 2009, which is hereby incorporated by reference in its entirety.
Furthermore, the techniques described above, for predicting utilization of health care resources and identifying plan members in need of proactive care services, can also be used by a health care plan or by a plan administrator to manage costs by adjusting premiums and predicting future needs of the member population.
When a member of a health care plan receives care from health care providers, information regarding the care received is provided to plan administrators in documents commonly referred to as claims. Predominantly, this information is provided in the following three types of claims: physician claims, facility claims, and pharmacy claims. These claims are the documents that are submitted to the health care plan by physicians, hospitals, and pharmacies to receive reimbursement for care provided to the plan member. These documents generally contain coded data that provides information regarding the care received by the plan member. These claims are processed by the health care plan, and where appropriate, payment is transmitted to the health care provider.
Analysis and identification of plan members amenable to proactive care intervention are performed using data from these claims. Typically data from all three claims is used in the analysis. Occasionally, a plan data administrator has access to only the pharmacy claims for the plan members. Accordingly, there is a need in the art for a method of performing modeling and analysis of plan members using only the data from pharmacy claims.
For purposes of this specification, the phrase “physician claim” is used to refer to any professional service claim submitted to a health plan (typically recorded on an HCFA-1500 form or its equivalent), and the phrase “facility claim” is used to refer to any facility claim (typically recorded on a UB92 form). The phrase “medical claim” is used to refer to both physician claims and facility claims. Finally, the phrase “pharmacy claim” is used to refer to any claim submitted by a pharmacy or durable medical goods provider. Medical claims generally include codes for diagnoses and procedures relating to the plan member. The reason for the visit is typically represented by an International Classification of Diseases (“ICD”) code, currently in its ninth revision and thus commonly referred to as “ICD-9.” The description of the service provided in a medical claim typically takes one of three formats, an ICD-9 procedure code, a Common Procedural Terminology (“CPT”) code (promulgated by the American Medical Association), or a Health Care Procedural Code (“HCPC”) (promulgated by the Health Care Financing Administration).
The following materials serve as background for the present application and provide further information on some of the classification systems discussed: Physician's Current Procedural Terminology, CPT 2003, specified by the American Medical Association; HCPCS 2003 Medicare's National Level II Codes, specified by CMS; Med-Index ICD9-CM Ninth Revision, specified by the World Health Organization (“WHO”), each of which is hereby incorporated by reference in its entirety.